Predictors of events of violence or aggression against nurses in the workplace: A scoping review

Abstract Aim To identify predictors and consequences of violence or aggression events against nurses and nursing students in different work contexts. Background Workplace violence against nurses and nursing students is a very common and widespread phenomenon. Actions to manage or prevent violent events could be implemented knowing the risk factors and consequences. However, there is a lack of systematic reviews that summarize knowledge on the predictors and consequences of workplace violence. Evaluation A scoping review was conducted using electronic databases including APA PsycInfo, CINAHL, Cochrane, Ovid Medline, PubMed and Scopus. Key issues After full text analysis, 87 papers were included in the current scoping review. Risk factors of horizontal violence were grouped into ‘personal’ and ‘Environmental and organizational’, and for violence perpetrated by patients into ‘personal’, ‘Environmental and organizational’ and ‘Characteristics of the perpetrators’. Conclusions The results of this scoping review uncover problems that often remain unaddressed, especially where these episodes are very frequent. Workplace violence prevention and management programmes are essential to counter it. Implications for Nursing Management The predictors and the consequents identified constitute the body of knowledge necessary for nurse managers to develop and implement policy and system actions to effectively manage or prevent violent events.


| BACKGROUND
The International Labour Organization defines 'workplace violence' as 'any action, incident or behaviour that departures from reasonable conduct in which a person is threatened, harmed, injured in the course of, or as a direct result of, his or her work' (ILO-International Labour Organization, 2003). The value of this definition lies both in its completeness (it covers all forms of violence), physical or psychological and in its inclusiveness (it does not exclude colleagues as a source of violence).
Health care professionals are often exposed to the risk of assault by patients or visitors. Workplace violence (WPV) among health care professionals, especially nurses, is the main occupational hazard in both developing and developed countries (Liu et al., 2019). A recent study reported that the prevalence of WPV against health care workers is high, especially in Asian and North American countries, psychiatric and emergency department settings, and among nurses and physicians (Liu et al., 2019).
More specifically, in North America, a survey conducted by the Emergency Nurses Association suggested that about one in every four nurses report having experienced physical violence more than 20 times in the previous 3 years and nearly a fifth report being verbally abused more than 200 times during the same period (Gacki-Smith et al., 2009). The Australian Incident Monitoring System showed that out of a total of 42.33 accidents, 9% (n = 3621) involved health care professionals in events of violence perpetrated by patients, relatives or visitors (Benveniste et al., 2005). Recently, a large study conducted in Australia showed that more than 75% of the nurses and midwives suffered from violence perpetrated by patients and visitors in the previous six months (Pich & Roche, 2020).
A European study conducted in 2019 showed that out of 260 nurses from five different countries, 20.4%, confirmed they had been physically assaulted in the workplace in the previous 12 months and 76.9% of these reported that it was unavoidable; 92.3% reported being assaulted by patients, family members or visitors in their professional career (Babiarczyk et al., 2019). In particular, the emergency room has been identified as a high-risk environment for WPV (Kowalenko et al., 2013), where nurses and trainees are the most exposed to this phenomenon (Chapman & Styles, 2006;Gerberich et al., 2005).
Although violent and aggressive patient behaviours are predominantly experienced by staff working in mental health units and emergency departments, patient violence and aggression are rising in other hospital areas, including general medicine and surgery units, paediatrics and intensive care (Ferri et al., 2016;Liu et al., 2019).
Outside the hospital, episodes of violence and assaults have been suffered in-home nursing services by 50% of nurses during their carriers (Fujimoto et al., 2017) and community care by 36% of nurses (Fafliora et al., 2016), as well as in pre-hospital, ambulance and rescue services by 41% of nurses (Coskun Cenk, 2019;Velden et al., 2015).
Given the spread and the impact of this phenomenon, many studies have analysed the consequences of violence against nurses involving both physical and psychological consequences such as anger, fear or anxiety, post-traumatic stress disorder symptoms (Hong et al., 2021), guilt, acute stress, decreased productivity (Al-Ghabeesh & Qattom, 2019b), reduced job satisfaction (Berlanda et al., 2019), increased intention to leave, lower quality of life and even death (Çam & Ustuner Top, 2021;Heslop et al., 2019).
The effects of violence in the health care setting may extend to the organization of the local service and entire health systems affecting the quality of services themselves. Health care organizations also incur in higher costs related to decreased productivity, poor job satisfaction and increased turnover (Speroni et al., 2014). Additional costs also result from lawsuits, compensation, and loss of revenue resulting from the negative image caused by violence incidents (Gerberich, 2004;Wax et al., 2016).
Although many health organizations around the world have implemented 'zero tolerance' policies for aggressors and established guidelines for the prevention and management of workplace violence, these policies often do not appear to work effectively in real life (Beattie et al., 2020;Hassankhani & Soheili, 2017;Morphet et al., 2014).
The most frequent risk factors of violence and aggression events include the characteristics of patients and nurses (e.g., gender, age and educational level) (Dangal et al., 2018;Zhu et al., 2021), weaknesses in leadership development or corporate policy implementation (Somani et al., 2021), poor training of personnel in the management of violence events (Jakobsson et al., 2021) and in recognizing risk situations, inadequate patient assessment and inadequate patient observation protocols , lack of communication between staff and patients, and their families (Yang et al., 2018) and deficiencies in the physical safety of the environment or in safety procedures (Babiarczyk et al., 2019;Najafi et al., 2018;Somani et al., 2021). All these factors and failure to recognize and respond to warning signals increase the risk of aggression or violence (Somani et al., 2021).
The identification of predictors or warning signals would enable health care professionals and managers to prevent and manage situations that could trigger events of violence in the workplace (Morphet et al., 2019). Furthermore, spreading the culture and knowledge of this phenomenon among health care professionals, managers and the general population could help to prevent the incidence of these episodes and protect both health care professionals and health service users.

| OBJECTIVES
To identify predictors of violence or aggression against nurses and undergraduate nursing students in different health care settings.
Secondary objectives: • Evaluate physical and psychosocial outcomes on nurses and undergraduate nursing students caused by violence or aggression and the economic and organizational consequences (unavailability and restoration of services).
• Describe episodes of violence or aggression against nurses and nursing students in the community setting.

Scoping review question
What are the predictors of the violence or aggression against nurses and students in different work contexts that enable their prevention or management?
Secondary questions: What are the physical and psychosocial outcomes on nurses and nursing students of violence or aggression and the economic and organizational consequences?
Which violence or aggression events against nurses and nursing students in the community are described in the literature?

| Study design
The present review was developed according to the Joanna Briggs Institute (JBI) guidelines for scoping reviews (M. Peters, Godfrey, et al., 2020). The scoping review methodology was further refined, and corresponding guidance was developed by a working group from JBI and the JBI Collaboration (JBIC) (Aromataris & Munn, 2020;Peters et al., 2015).
A research question was developed based on the PEO components: Population (types of participants), Exposure of interest (independent variable) and Outcome (dependent variable).
The PRISMA-ScR statement for scoping reviews (Tricco et al., 2018) was used to ensure the transparency of the study selection process.
The inclusion criteria are described in Table 1 1. An initial screening of titles, abstracts and keywords according to the inclusion and exclusion criteria. The papers were independently selected by four reviewers. Studies were excluded even if only one inclusion criterion was not met. All duplicates were removed.
2. Full texts eligible for inclusion were read and analysed.
An external expert in scoping reviews supervised the entire selection and analysis process. All the papers were separately examined by two researchers and in case of disagreement a third researcher was involved to reach an agreement. The reasons for the exclusion of the full texts were recorded to track the decisions that were taken.

| Data extraction
A data extraction sheet was developed according to the JBI guidelines for scoping reviews (M. Peters, Godfrey, et al., 2020).
The following data were collected: Study design/methodology, purpose/objectives, research questions/hypotheses, study context (setting), sample description, sample size, exposure, tools for measuring results, results, methods of data analysis (statistical analysis), conclusions, comments and issues raised.
Data were extracted separately by two researchers.

| Data synthesis
The results of the included studies underwent narrative synthesis, using words and text to summarize and explain the results. Its form varied from a simple account and description of the characteristics of the study, to the context, the quality and the results. Tables were used to compare the characteristics of the studies and the extracted data (Soilemezi & Linceviciute, 2018).

| Selection of the studies included in the review
A total of 15,523 records were initially identified after searching the databases. After titles and abstracts were screened, 121 papers underwent full text review. After reading the full texts, 87 papers were included in the current scoping review (see Figure 1, the PRI-SMA flow diagram).
T A B L E 2 Search concepts and keywords used (with appropriate Boolean operators) Of the studies included in the review, 59 analysed mainly the hospital setting and they involved all the departments (n = 31), the emergency room (n = 15), the psychiatric and mental health wards (n = 9), the operating room (n = 2), the medical and surgical departments (n = 1), the neonatal intensive care (n = 1) and in the trauma department (n = 1). Twenty-four studies involved both hospital and community settings, of these 22 included various departments, and 2 were in mental health. Studies that exclusively analysed the community context, in the home care setting, were the least represented (n = 4). All the details regarding the context and sample characteristics of the included studies are shown in Table 3.
Regarding the designs of the included studies, the cross-sectional descriptive design was adopted by 75 studies, 11 studies had a qualitative design and one a mixed-methods design ( Table 4).
The population mainly included nurses (85 studies), and nursing students (2 studies). All studies had higher percentages of female

Personal factors
Contrasting findings were reported with regard to nurses' gender; in some studies 'being a male nurse' was reported as a predictor (Chatziioannidis et al., 2018;Jaradat et al., 2016), whereas in others, 'being a female nurse' was considered a predictor (Anusiewicz et al., 2020;Park et al., 2015). In addition, being a young nurse (Bloom, 2019;Favaro et al., 2021;Reknes et al., 2014)  'Being female' is reported as a predictor of bullying for nursing students by Grainger and Whiteford (1993) and Lash et al. (2006).
According to Jafree (2017), having an age between 20 and 29 years, single marital status, and following the Muslim religion are predictors of horizontal violence.

Environmental and organizational factors
Attending clinical internship during the day shifts is reported as a predictor of horizontal violence for students by Grainger and Whiteford (1993) and Jafree (2017).

| Risk factors of violence suffered by nurses perpetrated by patients, family members or visitors
These include personal factors, environmental/organizational factors and characteristics of aggressors.

| Risk factors of violence suffered by nursing students perpetrated by patients, family members or visitors
Personal factors 'Being female' (Grainger & Whiteford, 1993;Lash et al., 2006), having an age range of 20-29 years and being single (Jafree, 2017) increase the risk of suffering violence among nursing students.

Risk factors of violence suffered by nursing students perpetrated by patients, family members or visitors References
Personal factors • Gender • Female Grainger andWhiteford (1993) Lash et al. (2006) • Age • Age between 20 and 29 years Jafree (2017) • Marital status • Being single Jafree (2017) Environmental and organizational factors • Being the least knowledgeable and least powerful group Lash et al. (2006) • During patient refusing a request Grainger (1993) • Placement in a psychiatric ward Grainger (1993) • Placement in emergency room Jafree (2017) Characteristics of the perpetrators • Inexperienced clinical instructors Lash et al. (2006) • Patients with aggressive behaviours Grainger (1993) Jafree (2017) Environmental and organizational factors Being in the least knowledgeable and with the least decisional power (Lash et al., 2006) together with being present when a patient refuses a request (Grainger & Whiteford, 1993) are seen as environmental and organizational predictors of violence. Also, internships in psychiatric wards (Grainger & Whiteford, 1993) or the emergency room (Jafree, 2017) are other risk factors.

Characteristics of perpetrators
Usually, the perpetrators of violence towards nursing students are either inexperienced clinical instructors (Lash et al., 2006) or patients with aggressive behaviours (Grainger & Whiteford, 1993;Jafree, 2017).

| Consequences of violence
The consequences of workplace violence suffered by nurses and nursing students reported in the included studies are divided into 'Professional life' and 'Emotional and psychological wellbeing' for horizontal violence, together with 'Physical consequences' and 'Consequences for the work environment, damage and costs' for violence perpetrated by patients and visitors. Table 6 shows details of WPV consequences.

Professional life
The most frequent consequence is the increasing intention to change workplace or to leave the nursing profession (Bambi et al., 2014;Blackstock et al., 2015;Favaro et al., 2021;Fontes et al., 2018;Kozakova et al., 2018).

Emotional and psychological wellbeing
At the same time the increasing of impulsiveness, anxiety and depression is the most frequent emotional and psychological consequence (Bambi et al., 2014;Blackstock et al., 2015;Favaro et al., 2021;Fontes et al., 2018).

Professional life
The most frequent consequences for nursing students of horizontal violence are the intention to leave the nursing programme (Clarke et al., 2012), the increased rates of absenteeism from internship placement (Lash et al., 2006).

Emotional and psychological wellbeing
The most frequently reported physical and emotional consequences are headache, loss of appetite and difficulty falling asleep (Lash et al., 2006).

Consequences for the work environment, damage and costs
The consequences for the workplace environment range from dam- leave from work for the recovery process (Favaro et al., 2021). WPV episodes increase staff turnover with a cost of up to $ 337,500; this leads to inability to hire, generating a toxic work environment and a lack of loyalty and cooperation (AbuAlRub et al., 2007). In a study conducted in the USA, the decrease in productivity was approximately $ 1300 for each nurse that experienced violence (Hutton & Gates, 2008).

Professional life
Consequences for students due to violence perpetrated by patients reported by the studies included in our review involve the increasing rates of absenteeism from internship placements (Clarke et al., 2012).

Emotional and psychological wellbeing
Studies reveal disturbing memories and negative thoughts (Clarke et al., 2012), loss of self-esteem and sense of helplessness (Lash T A B L E 6 Consequences of workplace violence reported in included studies

Consequences of horizontal violence suffered by nurses References
Professional life • Professional life Al-Ghabeesh and Qattom (2019b) • Quality of care provided • Less adequate responses and low patient safety Çelik and Çelik (2007) • Greater precariousness of work and with less control on clinical practices Park and Choi (2020) • Poor overall job satisfaction Hartin et al. (2020) Emotional and psychological wellbeing

| DISCUSSION
The phenomenon of workplace violence is widespread and documented worldwide. The literature describes violence mainly in hospital settings and in emergency rooms but also in community services and in various hospital departments. The present review enabled to identify several risk factors of WPV.

| Risk factors and consequences of horizontal violence
Horizontal violence is facilitated by specific personal factors of victims such as gender, age educational level and work experience. A way to promote integration and respect among professionals and prevent horizontal violence could be creating teams of nurses that have a good balance in terms of gender, age, a mix of work experience and skills to achieve common goals and greater autonomy (Edmonson & Zelonka, 2019).
Several environmental and organizational factors, such as poor nurse manager skills, rigid and hierarchical structures, understaffing, high levels of stress, shift work and unhealthy competition between professionals have been reported as additional risk factors for horizontal violence. The replacement of the current situation-oriented or task-oriented leadership with structural empowerment processes (Goedhart et al., 2017) aimed at achieving goals through access to information, support, resources and opportunities (Moura et al., 2020) can reduce bullying and mobbing. Furthermore, constant organizational changes and staff shortages increase nurses' stress levels. High levels of stress and job dissatisfaction, as well as leading to adverse patient outcomes (Bloom, 2019;Brooks Carthon et al., 2021;Schlak et al., 2021), create a favourable substrate for horizontal violence.
Nursing students suffer from WPV, too. Likewise, the students' personal factors such as gender, age, marital status and religion have been identified as risk factors of horizontal violence. In order to prevent the bullying of students, faculty members should acknowledge the inherent vulnerability of learners, their personal risk factors and also reflect on their own communication practices and how these impact on learners (Seibel & Fehr, 2018).  (Khera et al., 2021;Lasater et al., 2021). For this reason, the phenomenon of assaults perpetrated by patients may have increased in this period due to the critical shortage of nurses and the increased workload.

| Risk factors and consequences of violence perpetrated by patients or family members
Long waiting times in the emergency department (Morphet et al., 2014) associated with patients' unrealistic expectations has also been described as a major risk factor of physical and verbal aggression. In these cases, waiting time management strategies providing timely information and assistance to users, and specific education programmes for emergency personnel, could reduce the cases of aggression (Gillespie et al., 2014;Touzet et al., 2019). The lack of protocols and policies for the management and prevention of violence, the absence of dedicated communication channels and specific means to inform managers and administrators about episodes of violence are described by several studies (Babiarczyk et al., 2019;Jenkins et al., 1998). These shortcomings often occur in contexts where the incidence of violence against nurses is high (Cannavo et al., 2019). In addition, characteristics of the perpetrators, such as their mental status, clinical conditions and alcohol or drug abuse, have been identified as common risk factors of WPV. Greater awareness of the role played by these characteristics in WPV and advanced skills that enable to adequately approach these types of patients could help to predict, prevent, or limit the development of aggressive behaviors (Liu et al., 2019).
Nursing students also suffer violence perpetrated by patients and their families. Likewise, personal characteristics (e.g., gender, age and marital status) and organizational factors (e.g., attending emergency department internship) have been identified as risk factors. Teachers and clinical preceptors have a great responsibility in ensuring a safe learning environment. When personal characteristics and organizational and environmental factors are recognized as risk factors, they must be considered, together with the inherent vulnerability of learners, so that actions that protect students during their clinical learning programme are in place (Seibel & Fehr, 2018;Tee et al., 2016).
The consequences of WPV impact specifically on individual nurses, and generally on the health organization. These affect the quality of care provided, professional life and the emotional, psychophysical and physical well-being of nurses and nursing students. Physical and verbal assaults are related to burnout in each of its three dimensions (Laschinger et al., 2010;Wu et al., 2020;Yang et al., 2018). In this regard, the availability of follow-up programmes for WPV victims, counselling and discussion with hospital administrators have been found to reduce emotional exhaustion and depersonalization, and increase personal accomplishment (Vincent-Höper et al., 2020). In addition, burnout generated by violence reduces nurses' level of attention when providing care (Al-Ghabeesh & Qattom, 2019a), increasing the likelihood of errors and putting patients' safety and health at risk. On the other side, the poor quality of the care is perceived negatively by patients, who may not feel actively involved and receive unsatisfactory responses to their needs due to distracted nursing care.

| Economic consequences of workplace violence
Very few studies examined the economic consequences of violence but showed how costs incurred by health institutions rise significantly due to compensation measures for professionals who become victims of violence, their reintegration into the workplace and increased turnover. As in other studies (Jeong & Kim, 2018;Olsen et al., 2017), workplace violence is a significant cause of turnover intent. Constant turnover is an impediment to effective teamwork and cohesion among colleagues, or even worse, it may reinforce any negative attitudes that may harbour in senior staff (Van Bogaert et al., 2017). Furthermore, some consequences of violence, such as burnout, depersonalization and physical harm, also increase intention of turnover and intention to leave the profession that can lead to enormous costs for the health care organizations that have to cope with this phenomenon.

| Preventing and managing workplace violence
Nurse leaders are in the position to promote a culture of safety that prioritizes the health, safety and wellbeing of their staff, patients and visitors. Health managers should promote policies that refuse violence as an inevitable part of professional practice and allocate resources for the prevention and management of violence and bullying (Johnson et al., 2018;Pariona-Cabrera et al., 2020). Some studies identified strategies to manage and prevent WPV episodes at different levels.
For instance, allocating considerable funds to the prevention and management of WPV (Morphet et al., 2019), increasing staff numbers to prevent and manage WPV (Morphet et al., 2018), developing guidance materials evidence-based, focusing on education and training of staff to manage WPV (Geoffrion et al., 2020), implementing monitoring, responding and reporting systems (Burkoski et al., 2019;Ramacciati et al., 2021), sharing information between health services and other agencies and improving communication abilities (Collins, 2021) and implementing an effective security staff (Morphet et al., 2019).

| CONCLUSIONS
The results of this review bring to light critical issues often left unaddressed, especially where episodes of violence are very frequent.
WPV prevention and management programmes and proactive commitment are essential to reduce WPV and its consequences.
Nursing leaders must explore and implement practices towards mitigating violence against nurses. Action research is needed to engage in a cycle of continuous improvement that supports eliminating violence in the health care sector.
Initiatives for the health and safety of nurses that establish objectives and responsibilities to monitor and curb WPV, and reports describing the outcomes of the measures adopted to prevent and manage episodes of violence should be on the agenda of every health administration. There is sufficient evidence for nurse managers to ensure that nurses and all health care professionals feel protected and safeguarded from verbal or physical abuse, and work in environments that ensure maximum safety for everyone.

| Limitations
This review included papers about WPV suffered by nurses and nursing students excluding other health professions. Despite the inclusion criteria for this study being wide, limitations can be found in language restrictions (English and Italian) that may have excluded significant studies written in other languages. Most of the studies included in this review were from the North American Continent and Europe, which limits the generalizability of our conclusions.

| Implications for nursing management
The predictors and consequences of WPV identified through this review constitute the body of knowledge necessary for nurse managers to develop and implement actions to manage or prevent WPV effectively.
Therefore, there is sufficient evidence for nurse managers to contribute to the development of a positive safety culture and awareness, putting at its centre the health, safety and wellbeing of health personnel, patients and visitors. Nurse managers must promote policies that decline violence as an inevitable part of nursing practice and invest resources to neutralize the onset of episodes of violence and transform it into an opportunity for professional and cultural development.
Evidence-based management of violence can contribute to implementing actions that ensure a violence-free working environment through permanent monitoring and reporting systems.
Furthermore, this message on the impact of WPV in health care must also be spread to a broader audience to promote and support change effectively.

ACKNOWLEDGEMENT
This research received no specific grant from any funding agency in the public, commercial or non-profit sectors. Open Access Funding provided by Universita degli Studi di Genova within the CRUI-CARE Agreement.